- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,584.89 / $1,819.70
| Facility | | $1,479.11 | $1,584.89 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,570.40
| Professional | | $1,479.11 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,570.40
| Facility | | $2,238.72 | $2,238.72 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $2,238.72
| Professional | | $1,621.81 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,089.30 / $3,548.13
| Professional | | $776.25 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,862.09 / $2,290.87
| Professional | | $1,202.26 | $1,862.09 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,290.87 / $3,467.37
| Facility | | $1,380.38 | $2,290.87 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,698.24 / $2,290.87
| Professional | | $1,479.11 | $1,698.24 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $3,548.13
| Professional | | $1,862.09 | $1,862.09 | $3,548.13 |